Endoscopic ultrasound- versus ERCP-guided primary drainage of inoperable malignant distal biliary obstruction: Systematic review and meta-analysis of randomized controlled trials

Background We assessed efficacy and safety of endoscopic ultrasound-guided biliary drainage (EUS-BD) vs. endoscopic retrograde cholangiopancreatography (ERCP) as first-line intervention in malignant distal biliary obstruction (MDBO). Methods PubMed/Medline, Embase, and Cochrane databases were searched until 01/12/2023 for randomized controlled trials of EUS-BD vs. ERCP for primary biliary drainage in patients with inoperable MDBO. The primary outcome was technical success. Secondary outcomes were clinical success, adverse events, mean procedure time, 1-year stent patency, and overall survival. Relative risk (RR) with 95%CI were calculated using a random effects model. Results Five studies (519 patients) were included. RR (95%CI) for EUS-BD was 1.06 (0.96 to 1.17; P=0.27) for pooled technical success and 1.02 (0.97 to 1.08; P=0.45) for clinical success. 1-year stent patency was similar between the groups (RR 1.15, 0.94 to 1.42; P=0.17), with lower reintervention with EUS-BD (RR 0.58, 0.37 to 0.9; P=0.01). The RR was 0.85 (0.49 to 1.46; P=0.55) for adverse events and 0.97 (0.10 to 0.17; P=0.98) for severe adverse events. On subgroup analysis, EUS-guided placement of lumen-apposing metal stent (LAMS) outperformed ERCP in terms of technical success (RR 1.17, 1.01 to 1.35; P=0.03). Procedure time was lower with EUS-BD (standardized mean difference -2.36 minutes [-2.68 to -2.05; P<0.001]). Conclusions EUS-BD showed a statistically significant lower reintervention rate than ERCP, but with similar technical success, stent patency, clinical success, and safety. Technical success of EUS-BD with LAMS was better than ERCP.